A patient is one day postoperative following an open thoracotomy. The patient is receiving oxygen mist at 40% by Venturi mask. The patient's ABG results are: pH 7.31, PaO2 93 mm Hg, PaCO2 50 mm Hg, HCO3 25 mEq/L. Which of the following is an appropriate action for the nurse?

Elevate the patient in a high Fowler's position and encourage the use of an incentive spirometer and coughing.

Increase oxygen to 70%.

Switch oxygen to a rebreather mask.

Position the patient prone and have the respiratory therapist perform postural drainage.

Answer and Explanation

The Correct Answer is A

Choice A reason: Elevating the patient in a high Fowler's position can help improve lung expansion and oxygenation, and using an incentive spirometer along with coughing can help prevent atelectasis and pneumonia, which are common postoperative complications.

Choice B reason: Increasing oxygen to 70% without a specific indication could lead to oxygen toxicity, especially without assessing the patient's current oxygenation status.

Choice C reason: Switching to a rebreather mask is not indicated based on the given ABG results and could lead to CO2 retention.

Choice D reason: Positioning the patient prone and performing postural drainage are not typically first-line interventions for a patient one day post-thoracotomy and could be contraindicated due to the recent surgery.

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Correct Answer is A

Explanation

Choice A reason: Hyperventilation is a compensatory mechanism in metabolic acidosis where the body tries to decrease carbon dioxide levels to balance the acidity.

Choice B reason: Cold, clammy skin is not a typical manifestation of metabolic acidosis; it may be associated with shock or hypoglycemia.

Choice C reason: Increased blood pressure is not directly related to metabolic acidosis. It can be inﬂuenced by various factors, including stress or other underlying conditions.

Choice D reason: Bradycardia, or a slow heart rate, is not a common manifestation of metabolic acidosis. Tachycardia, or a fast heart rate, might be observed instead.

A. Administer sodium bicarbonate to the patient. B. Provide a paper bag for the patient to breathe into. C. Monitor the patient's head being between their knees. D. Administer acetazolamide to the patient.

Correct Answer is B

Explanation

Choice A reason: Administering sodium bicarbonate is not indicated for respiratory alkalosis as it is an alkalinizing agent and could worsen the condition.

Choice B reason: Breathing into a paper bag can help to rebreathe CO2, which can help correct the pH in cases of hyperventilation-induced respiratory alkalosis.

Choice C reason: Having the patient's head between their knees is not a standard intervention for respiratory alkalosis and could be uncomfortable or unsafe for the patient.

Choice D reason: Acetazolamide is a diuretic that can cause metabolic acidosis to compensate for respiratory alkalosis, but it is not typically used for acute management of hyperventilation.

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A patient is one day postoperative following an open thoracotomy. The patient is receiving oxygen mist at 40% by Venturi mask. The patient's ABG results are: pH 7.31, PaO2 93 mm Hg, PaCO2 50 mm Hg, HCO3 25 mEq/L. Which of the following is an appropriate action for the nurse?

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Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a patient who has alcohol use disorder and is experiencing metabolic acidosis. Which of the following manifestations should the nurse expect?

Correct Answer is A

Explanation

A nurse is caring for a patient who has respiratory alkalosis and hyperventilating. Which of the following interventions should the nurse implement?

Correct Answer is B

Explanation

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